VIASYS info Special Edition CPET, April 2002
The tolerable range of work rates in patients with lung disease is constrained by a com- bination of factors, chief of which are:a)impaired pulmonary-mechanical and gas exchange function which increases the de-mand for airflow and ventilation; b)limitations in response capabilities, either of airflow generation or of lung distensi-on;c)increased physiological costs of meeting the ventilatory responses, in terms of respi-ratory muscle work, blood flow and O
consumption;d)predisposition to 'shortness of breath' or 'dyspnoea' as a consequence of the highfraction of the achievable ventilation demanded by the work rate, commonly exacer- bated by arterial hypoxaemia; ande)the often-marked reduction in the range of spontaneously-selected daily activities,which results from the dyspnoea, and further reduces the state of physical training.
Brian J. Whipp, Ph.D., D.Sc.Centre for Exercise Science and Medicine, University of Glasgow,Glasgow, UK
To address the role of exercise testing in elucidating the causes of exercise intolerance,with particular reference to pulmonary disease.To discuss the value of clinical exercise testing, in:a)establishing the limits of system function b)defining the effective operating rangec)identifying potential causes of exercise intoleranced)evaluating the normalcy of the response with regard to a reference populatione)establishing the normalcy of response with regard to other physiologicalfunctionsf)providing a frame of reference for change with respect to therapeuticinterventions or training, andg)as a means of "triggering" an abnormality.To emphasise the importance of domains of exercise intensity and identifying thedeterminants of an "appropriate" ventilatory response, including considerations of:a)to what extent are the "requirements" met? b)what is the "cost" of meeting these requirements?c)to what extent is the system "constrained" or "limited"? andd)how "intensely" is the response perceived?To establish the physiological basis of the profiles of cardiopulmonary system responsesto incremental exercise performed to the limit of tolerance.To recognise when the value of a particular variable or its response profile reflects anabnormality of system(s) functioning, both with respect to(a)the work rate itself or to other related variables and(b)consideration of responses that are often misrepresented as reflecting systems behaviour.
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Strategies designed to increase exercisetolerance in such patients should thereforeattempt both to increase (where possible) theventilatory limits, reduce the demand for ventilation and reduce the intensity of, or attempt to desensitize the subject to, theconsequent dyspnoea.In order to meet the increased demands for pulmonary gas exchange during exercise, thelungs must replenish the O
extracted fromthe alveoli by the increased flow of moredesaturated mixed venous blood. This preserves alveolar, and hence arterial, O
partial pressure. The lungs must also provideto the alveoli diluting quantities of CO
-free(atmospheric) air at rates commensurate withthe increased delivery rate of CO
in themixed venous blood. This maintains alveolar,and hence arterial, PCO
. However, themetabolic (chiefly lactic) acidosis of high-intensity exercise requires that alveolar andarterial PCO
be reduced to provide acomponent of respiratory compensationwhich constrains the fall of arterial pH.The pulmonary system is therefore confron-ted by different demands for blood-gas andacid-base regulation during exercise. Thereare competing ventilatory demands for alve-olar PO
regulation when the re-spiratory exchange ratio differs from unity,and also for arterial PCO
and pH regulationwhen the exercise results in a metabolic aci-dosis. In patients with lung disease, this pro-cess is further complicated by pulmonary gasexchange inefficiencies which result in of-ten-marked differences between alveolar (either ëidealí or ërealí) and arterial gas par-tial pressures. Consequently, the impaired pulmonary gas exchange in patients withchronic lung disease further increases theventilatory demand during exercise; the im- paired pulmonary mechanics, however, cons-trains or even limits the ability to meet thedemands.